The Uttar Pradesh Occupational Safety, Health and Working Conditions Rules, 2026
Form 11
Official text
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{See sub-rule (3) of rule 15}
Notice of dangerous occurrence
1. Name and address of Establishment...................................................................................
2. Name of the Occupier/Employer...............................................................................................
3. Name of the Manager.................................................................................................
4. Name of Industry......................................................................................................
5. Branch or Department and exact place where the dangerous occurrence took place.................
6. Date and hour occurrence...........................................................................................
7. Nature of Accident or Dangerous Occurrence (state exactly what happened).
8. Details of Employees affected by such dangerous occurrence.
Sr.no Name of the Employee Employee Code Designation
I certify that, to the best of my knowledge and belief, above particulars are correct in
every respect.
Signature of the Occupier /
Employer/ Manager.
Date of dispatch of report…………………….
(This space to be completed by Inspector-cum-Facilitator)
District........................................................................... Date of receipt...............................................
D.O. No................................................................. Date of investigation......................................
Causation No................................................................
Result of investigation: